Ninety-five percent of disability claims are denied solely on the basis of an internal medical report written by any number of “Board Certified” insurance physicians. In the 26 years I’ve been reviewing disability file data it has become apparent to me another “pattern of business practice” is the format in which these medical reviews are written, and the fact they appear to be identical in format. This format is used by ALL the major insurance companies and is not unique to any one company in particular.
The format is deliberate and is constructed in a way suggestive of credibility making it hard for federal or state regulators, judges or juries to discount it. Everything documented in an internal insurance medical report is for the purpose of placing more weight, and more crediblity to it than normally should be given to a report from a physician with no treatment history with the insured and based solely on paper notes.
(If you have your file documents I strongly suggest you pull out one of the many internal physican reviews and verify the format I’m going to describe to you. Nearly all internal physician medical reviews are the same in format.)
Here is the pattern all internal medical reviews appear to follow. Its purpose is to create the illusion of factual reporting and credibility. I’d like the readers to really think about this. Disability insurers use that old, “if it looks like duck, acts like a duck, then it must be a duck” adage. If the insurance medical report quacks like a duck, it must be a duck, and everyone who reads it will think its the real duck. Actually, the report has some “quack” in it, but its certainly not the duck.
The first part of an insurance medical review involves listing, and/or describing all of the individual medical patient notes, labs, reports and other information submitted by the insured and his/her physicians. This is documented because the insurance physician wants the reader to: 1) believe the medical review “considers” the opinions of the insureds doctors and 2) the file is complete i.e. all available medical information is being reviewed. In fact, the insurance physican may not actually review ALL of the information listed and will disregard it anyway. But, the list of extensive patient notes in the report has a way of convincing the reader the informtion was considered, when in fact it was not. Secondly, a long list of documents does not factually prove ALL claim information has been included in the review.
- Next, the reviewing physican will “snatch” and “twist” information from each document and disagree with it. Each document will be mentioned with a non-factual interpretation and an explanation as to why the information could not possibly preclude the insured from working.
- The same key phrases are always used – such as “the restrictions and limitations do not preclude work capacity” or “there is no objective evidence indicating the insured is not able to work”, or I find the primary care physican over resticts the insured and he/she is able to perform sustainable work.” The key phrases are always the same ones even when there is no “objective evidence” standard in the file.
- The conclusion of an internal medical review ususally begins, “…based on my review of all of the above listed information, it is…….” There are always 1) conclusionary remarks repeating the information that was reviewed; 2) why the insureds physicians and treatment providers are wrong in their assessment; 3) why the insurance physician’s opinion is the only right one; and 4) statements that the insured can work in some capacity, either part or full time.
- The internal physician will always sign in the format of a signature block. Just underneath his name, will apear credentials such as “Board Certified in Internal Medicine”, or Cardiologist as a specialty. The insurance company wants to make sure it gets a return on its credential investment which adds up. The credentials also give the report the illusion that it was performed by a physician who is a specialist in the area for which the insured is disabled.
Insurance internal medical reviews create the illusion of credibility and factualness when in fact the reports have little to do with the reality of the disabled person or their realistic physical or mental capacity for work.
So many times insureds have said to me, “I can’t believe they said that because I really can’t work.” Insurance medical reviews are deliberately NOT intended to report or document the truth, but rather to create an illusionary perspective of supporting the business interests of the insurance company to not pay claims. Period. Insurance companies pay a great deal of money to physicians who can create an Aesop’s fable when they need one.
Further, these reports actually have nothing to do with any insureds actual medical condition, restrictions and limitations provided by the insureds doctors, or any realistic perspective of the insureds true work ability. And, the format of the reports are deliberate.
Another example is the use of the term “Independent Medical Examination.” Most lay persons on a jury, or judges, employers, and agencies will see the word “independent” and immediately conclude “unbiased.”
Why can’t we use the term “Insurance Medical Examination”, which is still an IME? Insurance companies would NEVER approve the word “Insurance” over “Independent” because the term would be suggestive of “shady”, or “inappropriate.” In reality, the word “Independent” refers to the fact that the insured will be seen by a physician whom he/she has never consulted before, but people may still think the exam was objective and fair. Simply not so.
Mental and nervous disabilities really get to me. How can an insurance physician who has no treatment history with the insured have more weight than a therapist or psychiatrist who has been consulting with the insured every week? DSM-IV diagnoses are for the most part clinical in nature; without the clinical experience with the insured there is no way to “interpret” patient psychotherapy notes written by another therapist, except that you cipher the documents in the company’s favor. This is an obvious bias.
Make no mistake. Internal medical reports are constructed in such a way as to persuade readers the reports are credible. This is deliberate with the full intent of creating an illusion about the insureds disability which supports the profitability of the company resulting from NOT paying claims. Think about it. Internal insurance physicans are paid a great deal to document medical fairy tales.
